Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation of a Quality Improvement Project in a Large Health System

Abstract

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent prescriptions for opioids and benzodiazepines or sedative/hypnotics, a diagnosis of substance use disorder, or a history of opioid overdose. Our interventions included (1) a standing order for naloxone in the hospital pharmacy, (2) in-person naloxone trainings for all clinical and non-clinical primary care staff, (3) online training modules, (4) guidelines on naloxone co-prescribing sent via email, and (5) automated alerts in the electronic medical record (EMR). To evaluate these interventions, the EMR for, was queried for patients with one or more risk factors for opioid overdose, and whether they had naloxone on their medication list between 2017 and 2020. Results: Over the course of the study period, overall rate of naloxone co-prescribing system-wide increased from 0.4% to 26% of patients. Automatic EMR alerts were associated with an increase of 4.5%, the largest single-quarter increase. Online education modules and guideline dissemination were associated with smaller increases of 0.9% and 3% in the two quarters following their implementation. In-person trainings and making naloxone available without a prescription were followed by Conclusions: Our most effective intervention was automatic alerts in the EMR, while e online trainings and guidelines produced modest effects. A notable increase was also seen in one hospital system whose entire leadership and staff deliberately prioritized increasing naloxone access. Even with these gains, we have not yet achieved adequate co-prescribing across our system.